MINISTRY OF HEALTH AND SOCIAL WELFARE
NATIONAL MANAGEMENT GUIDELINES FOR HEALTH SECTOR RESPONSE AND PREVENTION OF GENDER-BASED VIOLENCE [GBV]
AUGUST , 2011
TABLE OF CONTENTS
FOREWORD vii
ACKNOWLEDGMENT viii
GLOSSARY OF TERMS AND CONCEPTS ix
SECTION ONE: INTRODUCTION 1
1.1 Overview of Gender-Based Violence 1
1.2 Characteristics of GBV in Children and Adolescent Abuse 2
1.3 Tanzania Policy Environment for GBV 3
1.4 Tanzania's Legal Environment for GBV: 3
1.5 GBV and Health Consequences 5
1.6 Government and Multi Sectoral Initiatives to Respond to GBV 5
1.7 GBV Policy Guidelines and Guidelines for the Management of GBV 6
1.8 Health Sector and GBV 6
1.9 National Health and Social Welfare Services Delivery infrastructure 7
SECTION TWO: RATIONALE AND OBJECTIVES 10
2.1. Why Guidelines for Management of GBV? 10
2.2 Users of this Guideline 10
2.3. Guiding Principles for Care of GBV Survivors 10
2.4. Objective of the Guideline 13
SECTION THREE: LINKAGES OF HEALTH FACILITY WITH COMMUNITY 14
3.1 Health Providers Message to Survivor and Community 14
3.2 Support to Community Initiative 15
3.3 Safe House 17
SECTION FOUR: STANDARDS FOR MEDICAL MANAGEMENT OF GBV SURVIVORS 18
4.1 Integration GBV Services into existing health services 18
4.2 Minimum Standards of GBV Services by Levels of Health Facilities 20
4.3 Summary of Comprehensive GBV Services and Standards 26
SECTION FIVE: GUIDING PRINCIPLES:- HUMAN RIGHTS, ETHICS AND COMPASSION 28
5.1 Values in Management of GBV Survivors 28
5.2 Procedures for Medical Care to a GBV Survivor 28
5.3 Rights of the Survivor 29
5.4 Obligations of the Service Provider: 30
5.5 Criteria of Obtaining Informed Consent in Children [UN]. 30
SECTION SIX: MEDICAL MANAGEMENT OF GBV [Over 18 Years] 32
6.1 Introduction 32
6.2 Receiving the Survivor 32
6.3 History Taking For Adults 33
6.4 Physical Examination 35
6.5 Laboratory Investigations 36
6.6 Diagnosis 37
6.7 Treatment of GBV Survivors 37
6.8 Preventive Treatments 38
6.9 Follow up care and Treatment and/or Referral 39
6.10 Documentation 39
SECTION SEVEN: MEDICAL MANAGEMENT : CHILDREN & ADOLECENTS ABUSE 40
7.1 Introduction 40
7.2 Receiving the survivor 44
7.3 History Taking 45
7.4 Physical Examination 49
7.5 Laboratory Investigations 52
7.6 Diagnosis 52
7.7 Treatment 53
7.8 Preventive Treatments 53
7.9 Follow up Care and Treatment and/or Referral 56
7.10 Documentation 56
SECTION EIGHT: linkages for GBV PREVENTION AND SERVICES 57
8.1. Introduction: 57
8.2. Linkage for Preventive Service: 57
8.3. Linkage for GBV Service to Survivors 57
8.4. Integration and Coordination for GBV Services 58
8.5. Monitoring, Evaluation for GBV Services 58
ANNEX 1: SALIENT FEATURES OF GBV IN CHILDREN 60
ANNEX 1.1 TYPES OF GENDER-BASED VIOLENCE IN CHILDREN 60
ANNEX 1.2 WHO IS THE PERPETRATORS? 60
ANNEX 1.3 RISK FACTORS FOR GBV IN CHILDREN AND ADOLESCENTS 60
ANNEX 1.4: PHYSICAL AND BEHAVIORAL INDICATORS OF CSA 61
ANNEX 1.5: SYMPTOMS OF RAPE TRAUMA SYNDROME IN CHILDREN 61
ANNEX 1.6: COMMON COMPLAINTS OF CHILD AND ADOLESCENT ABUSE 61
ANNEX 1.7: COMMUNICATING WITH CHILDREN GUIDE 62
ANNEX-2: CLASSIFICATION OF GBV INJURIES 62
ANNEX 3: SUMMARY OF PREVENTIVE TREATMENTS 63
ANNEX-4 RECOMMENDED GBV FORMS: 66
ANNEX: 4.1 CONSENT FORM: 66
ANNEX: 4.2: POLICE FORM NUMBER THREE (PF3) 66
ANNEX 4.3: PROPOSED GBV REGISTER: 68
ANNEX: 4.4: GBV MEDICAL FORM 69
ANNEX 4.5 PICTOGRAM 72
ANNEX 5: PSYCHOSOCIAL SUPPORT GUIDES 73
ANNEX 5.1: BASIC PSYCHOSOCIAL INTERVENTIONS GUIDE (child) 73
ANNEX 5.2: PRETEST COUNSELING GUIDE 73
ANNEX 5.3: POST TEST COUNSELING GUIDE 74
ANNEX 5.4: TRAUMA COUSELING GUIDE 75
ANNEX 5.5: ADHERENCE COUNSELING GUIDE 76
ANNEX 6 GUIDE ON WHEN TO REFER 76
ANNEX 7: GBV INDICATORS FOR THE HEALTH SECTOR 77
ANNEX 8: RESOURCE CENTERS 77
REFERENCES 78
ACRONYMS AND ABBREVIATIONS
AIDS Acquired Immune Deficiency Syndrome
BPA Beijing Platform of Action
CBOS Community Based Organizations
CEDAW Convention on Elimination of All Forms of Discrimination against Women
CSOs Civil society organisations
CTC Care and Treatment Clinics
DNA Deoxyribonucleic Acid
DPs Development Partners
EC Emergency Contraceptive
ECSA East, Central, and Southern African (ECSA) Health Community
FBOs Faith-based organisations
FGC Female Genital Cutting
FGM Female Genital Mutilation
FP Family Planning
GBV Gender-based violence
GFPs Gender Focal Points
HIV Human Immuno Deficiency Virus
HPI Health Policy Initiative
HTC HIV Testing and Counseling
IASC Inter-Agency Standing Committee
MCDGC Ministry of Community Development Gender and Children
MCH Maternal and Child Health
MDAs Ministries, Departments, Agencies
MDGs Millennium Development Goals
MKUKUTA ‘Mkakati wa Kukuza Uchumi na Kupunguza Umaskini’ Tanzania
MOEVT Ministry of Education and Vocational Training
MoHA Ministry of Home Affairs
MOHSW Ministry of Health and Social Welfare
MoJCA Ministry of Justice and Constitutional Affairs
MoU Memorandum of Understanding
MTEF Medium Term Expenditure Framework
MVCs Most Vulnerable Children
NGOs Non-Governmental Organisations
NSAs Non-state actors
PAF Performance Assessment Framework
PEP Post Exposure Prophylaxis
PEPFAR President’s Emergency Plan for AIDS Relief
PF3 Police Form number 3
PLHIV Person Living With HIV/AIDS
PMO-RALG Prime Ministers’ Office Regional Administration and Local Government
PMTCT Prevention of Mother to Child Transmission Of HIV
PTSD Post Trauma Stress Disorder
RCHS Reproductive and Child Health Section
RH Reproductive Health
RTIs Reproductive Tract Infections
SOPs Standard Operation Procedures
SOSPA Sexual Offences Special Provisions Act
STIs Sexually Transmitted Infections
TARWOC Tanzania Rural Women and Children Development Foundation
TPFNet Tanzania Police Female Network
TWG Technical Working Group
UN United Nations
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
UNJP 2 United Nations Joint Program 2
USAID United States Agency for International Development
VAC Violence Against children
VAW Violence against Women
VEO Village Executive Officer
VICOBA Village Community Bank
WEO Ward Executive Officer
WHO World Health Organization
YWCA Young Women Christian Association
FOREWORD
This guideline is designed to assist health care providers with the skills needed to prevent and respond to Gender Based Violence (GBV). GBV is a serious health and human rights challenge with negative consequences that impact on women, girls, children, men, boys; and Tanzania is not an exemption. Women, girls and children are the most affected. GBV also hampers the gains made in the fight against the spread of HIV/AIDS and in Sexual, Reproductive and Child Health. This coupled with Domestic Violence and Child Abuse calls for comprehensive measures to address these harmful practices.
The guide provides standards for provision of quality and comprehensive medical services and procedures to GBV survivors; encourages providers to identify and find urgently required resource materials and find medications for GBV service delivery points. The guideline builds on the existing Health Policy and provides a framework to guide comprehensive management of GBV survivors that encompasses medical management, referral, psychosocial support with linkages to social and legal protection and systems. However, comprehensive management of GBV survivors demands coordination within the health sector and close collaboration with other sectors and key stakeholders. This calls for comprehensive systems for monitoring and evaluating GBV interventions.
.The Management guidelines have come in timely at a period in the country when the HIV/AIDS epidemic is still a problem. Media reports frequent occurrences of GBV especially wife beatings and killings and child rape. On the positive side Tanzania has a National Plan of Action for the prevention and eradication of violence against women and children 2001 to 2015 which was developed to augment government efforts to combat GBV and to ensure equity between women and men. So as to safeguard the dignity of women, it includes apart from sexual violence; rape, sexual harassment and cruelty to children. For the first time, Tanzania took a legislative stance against the practice.
This Management guideline is a valuable tool in the hands of health managers and service providers. The ministry shall ensure that these guidelines are available in all health facilities and that their implementation will help address the needs of GBV survivors in Tanzania in a holistic and comprehensive manner. Let us join our efforts in eradicating GBV in Tanzania.
Dr. Deo Mtasiwa
Chief Medical Officer
Ministry of Health and Social Welfare
ACKNOWLEDGMENT
The National Management Guidelines for Health Sector Response and Prevention of Gender-Based Violence would not have been developed without the support and contribution of many GBV stakeholders in the country. The Ministry of Health and Social Welfare (MOHSW) sincerely acknowledges the great effort, dedication and hard work of many tireless representatives from numerous organizations in developing the guidelines.
Foremost, MOHSW expresses deep gratitude to the United States Agency for International Development (USAID) and the President’s Emergency Plan for AIDS Relief (PEPFAR) for their generous financial support in developing this guideline. MOH&SW greatly acknowledges the Health Policy Initiative (HPI) for providing continuous guidance and invaluable technical assistance and USAID/PEPFAR for their continuous support in the development of the comprehensive GBV Management Guidelines. HPI also provided Secretariat as well as considerable support to the GBV Technical Working Group (TWG), which played an important role in the development of the guidelines.
Similarly the MOHSW extends its sincere appreciation to the United Nations Joint Program for reduction of Maternal and Newborn Mortality (UN/JP2), which is managed by UNFPA, and also includes WHO, UNICEF, ILO, WFP and UNESCO, for the continuous and valuable technical and financial support to the development of the GBV Management Guidelines.
The MOHSW appreciates and commends the role played by its Reproductive and Child Health Section (RCHS) in providing leadership and effective coordination. MOHSW also takes the opportunity to thank other Ministries and agencies for their participation and contribution to the development of the GBV Management Guidelines; in particularly the Ministry of Community Development, Gender and Children; Ministry of Education and Vocational Training; Ministry of Justice and Constitutional Affairs; Ministry of Home Affairs; Ministry of Finance and Economic Affairs; Ministry of Local Government and Regional Development; and Tanzania Commission for AIDS (TACAIDS).
MOHSW also thanks all the civil society organizations (CSOs) that shared their GBV experiences and made useful contributions, including but not limited to: Medical Women Association of Tanzania (MEWATA); House of Peace; Women’s Dignity Project; WILDAF; Women’s Legal Aid Center (WLAC); Tanzania Media Women Association (TAMWA); and Mwalimu Nyerere Gender Institute, just to mention a few.
Last but not least, great recognition goes to the members of the GBV TWG consisting of representatives from the Ministries and CSOs mentioned above. They truly created a multi-disciplinary team of experts who ensured completion of the GBV Management Guidelines. Finally, a special tribute goes to those who edited and finalized this document.
Dr. Donan Mmbando
Director for Preventive Services
Ministry of Health and Social Welfare
GLOSSARY OF TERMS AND CONCEPTS
For the purpose of this document, these terms and concepts shall have the following meanings.
Abuse: Misuse of power through which the perpetrator gains control or advantage of the abused, using and causing physical or psychological harm or inflicting or inciting fear of that harm. Abuse prevents persons from making free decisions and forces them to behave against their will.
Adolescent: The transitional stage of development between childhood and full adulthood, representing the period of time during which a person is biologically an adult but emotionally not achieved full maturity. The time is identified with dramatic changes in the body associated with onset of puberty along with developments in a person's psychology. In the onset of adolescence, children pursuing an academic career usually complete primary school and enter secondary schools.
Child: Someone who is not yet an adult or someone who has not yet reached puberty; a person who is younger than age 18 years.
Child abuse or child neglect: Any act or failure to act on the part of a parent, caretaker or any adult which results in physical or emotional harm, sexual abuse
Child Sexual Abuse: the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violate the laws or social taboos of society. Child sexual abuse is evidenced by this activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust or power, the activity being intended to gratify or satisfy the needs of the other person. This may include but is not limited to: the inducement or coercion of a child to engage in any unlawful sexual activity, the exploitative use of child in prostitution or other unlawful sexual practices and the exploitative use of children in pornographic performances and materials. Child abuse is an umbrella term that included deliberate and intentional words or overt actions that cause harm, potential for harm, threat of harm to a child. Child abuse can take three broad forms, namely physical abuse, sexual abuse and psychological abuse.
Coercion: Forcing, or attempting to force, another person to engage in behavior against her/his will by using threats, verbal insistence, manipulation, deception, cultural expectations or economic power.
Comprehensive: Covering and involving broadly all relevant aspects and key players at all levels.
Consent: Making an informed choice to freely and voluntarily to do something. There is no consent when agreement is obtained through the use of threats, force or other forms of coercion, abduction, fraud, deception, or misrepresentation. Threatening to withhold, or promising to provide a benefit in order to obtain the agreement of a person constitutes an abuse of power. Any agreement obtained in such a way, or from a person who is below the legal (statutory) age of consent, or is defined as a child under applicable laws, is not considered to be consensual.
Domestic violence: {Also known as domestic abuse, spousal abuse, family violence, and intimate partner violence (IPV)}
A pattern of abusive behaviors by one or both partners in an intimate relationship such as marriage, dating, family, friends or cohabitation. Domestic violence has many forms, including physical aggression (hitting, kicking, biting, shoving, restraining, slapping, throwing objects), or threats thereof; sexual abuse; emotional abuse; controlling or domineering; intimidation; stalking; passive/covert abuse (e.g., neglect); and economic deprivation.
Drop in Centre: A place for call for information, safety, referral first aid and other issues of immediate attention for GBV survivors who need a safe and confidential place for a limited period of time.